Chronic active antibody mediated rejection (c-aABMR) is a major cause of long-term kidney allograft loss. It is hypothesized that frequent sub-therapeutic exposure to immunosuppressive drugs, in particular tacrolimus (Tac), is a risk factor for the development of c-aABMR. The intra-patient variability (IPV) in Tac exposure may serve as a substitute biomarker for underexposure and/or non-adherence. In this study, the association between Tac IPV and the development of c-aABMR was investigated.0), Tac IPV, renal allograft function and graft survival were compared between the groups.We retrospectively included 59 patients diagnosed with c-aABMR and compared them to 189 control patients matched for age, year of transplantation and type of kidney donor. The Tac IPV was calculated from pre-dose tacrolimus concentrations measured over a 3 year period preceding the diagnosis of c-aABMR. The mean Tac predose concentrations (Cversus 23.6% for the controls (p = 0.47). The mean Tac C0 was comparable for the cases (5.8 ng/mL) and control patients . Only in the c-aABMR group a significant decline in both mean Tac C0 and allograft function over the timespan of 3 years was observed (p = 0.03 and p<0.001). Additionally, in the group of c-aABMR patients a high IPV was associated with inferior graft survival (p = 0.03).Tac IPV was 24.4% for the cases per se does not predispose to the development of c-aABMR but is associated with inferior graft survival once c-aABMR is diagnosed.A high Tac IPV  Despite a significant improvement in short-term kidney allograft survival in the past decade, long-term kidney allograft survival has remained relatively unchanged. ChronicIn most centers, tacrolimus (Tac) is the cornerstone of the maintenance immunosuppressive regimen after renal transplantation. Tac is For this retrospective case-control study, all kidney transplant recipients transplanted in our center between 2000 and 2013 were eligible. The main inclusion criteria was the use of Tac as maintenance immunosuppression for both cases and controls. The year 2000 was chosen because then Tac became the CNI of choice in our center.0 were aimed at levels between 5–7 ng/ml. There were no other inclusion criteria regarding the use of other (maintenance) immunosuppressive drugs. This retrospective study was reviewed and approved by the Institutional Ethics Committee from the Erasmus MC, Rotterdam, The Netherlands. Due to the retrospective nature of the study no informed consent was needed.The standard immunosuppressive regimen did not include induction therapy before the year 2006–2007. Thereafter, patients received induction therapy with basiliximab and were set on a triple immunosuppressive regimen consisting of tacrolimus, mycophenolate mofetil and prednisolone after transplantation. In the first year after transplantation prednisolone was slowly tapered to 0 after 3 months. As per local protocol, the administration of Tac was slowly tapered after the first 6 months and Tac CPatients diagnosed with histologically-proven (suspicious) c-aABMR were defined as cases. The cases were selected from the pathology database at our center and were diagnosed after a for-cause biopsy. The diagnosis of c-aABMR was made at time of biopsy by an experienced renal pathologist based on the current Banff classification–21. Pativersus living) and a minimal graft survival which resembled the cases’ time to c-aABMR diagnosis. The matching process was performed by coding all patients, both cases and controls, for the aforementioned factors. By means of an algorithm patients were found to be a positive match if all 4 factors were alike. The matches were selected from the transplantation database of our center. For every single c-aABMR case all possible matches were included.As a control group we selected kidney transplant recipients that showed no evidence of c-aABMR. All patients in the control group have had no clinical suspicion of c-aABMR until point of inclusion. Additionally, if present, all previous biopsy results have been screened for signs of (suspicious) c-aABMR. Controls were matched for age, year of transplantation, type of kidney donor (deceased i.e. nondose-corrected) tacrolimus whole-blood, pre-dose concentrations were collected. Only Tac C0 measured after month 6 after transplantation were included, to allow for stabilization of drug dosing versus a mean Tac C0 of 6.1 ng/mL [range: 3.6 ng/mL-10.0 ng/mL] for the controls (p = 0.08).Similarly, there was no significant difference in mean Tac C0 during the 3 years preceding the diagnosis of c-aABMR among cases but not controls (versus p = 0.18 for controls). When mean Tac C0 was analyzed per year, patients who developed c-aABMR had a mean Tac C0 of 6.1 ng/mL between t-3-t-2, which fell to 5.8 (t-2-t-1) and 5.4 ng/mL (t-1-t-0) in the years thereafter. Controls had a similar mean Tac C0 to the cases between t-3-t-2  which in the years thereafter showed no decline (6.3 ng/mL (t-2-t-1) and 5.9 ng/mL (t-1-t-0)). The difference in mean Tac C0 in the year prior to endpoint (t-1-t-0) between the cases and controls was significant at a P-value of 0.03.There was however a significantly declining trend noted in mean Tac Ccontrols  (p = 0.0-3) of 48 ml/min/1.73m2 and 50 ml/min/1.73m2, respectively (p = 0.55). In the following years the cases had a substantial decline in allograft function. The average eGFR of the cases deteriorated from 48 ml/min/1.73m2 3 years before the diagnosis of c-aABMR to 45 (t-2), 42 (t-1), and 32 ml/min/1.73m2  to 49 (t-2), to 48 (t-1), and to 47 ml/min/1.73m2 . However, in the 2 years thereafter the cases had a significantly inferior allograft function compared to the controls (p = 0.005 at t-1 and p<0.001 at t0).Cases and controls showed a similar allograft function at start of analysis  was 18.5% and 30.4% for the high IPV group (>24%). Notably, a high IPV was significantly associated with inferior graft survival (To assess the association of intra-patient variability and Tac Cp = 0.03). Howeverp = 0.03). The con0 did not show any differences for either the case or control group .In this retrospective case-control study we tested the hypothesis that a high IPV of tacrolimus predose concentrations is associated with a higher risk for developing chronic-active antibody mediated rejection of the kidney allograft. However, we found that in cases with c-aABMR the IPV for tacrolimus in the years prior to the diagnoses was similar to the IPV of matched controls.0 are very common in the first weeks or months after transplantation due to numerous causes such as drug-drug interactions, tapering of corticosteroid doses and/or changes in gastro-intestinal motility. Typically however, after a couple of weeks or months patients reach a more stable situation as the inter-occasion variability decreases. The differences in Tac C0 tend to get smaller over time. Fluctuations in Tac C0 in the maintenance phase after transplantation may therefor represent suboptimal patient-adherence. The calculated intra-patient variability of Tac C0 is considered a surrogate marker for non-adherence[Fluctuations in Tac Cadherence, 10, 23.0. One of which is the variance (σ2). The variance is used for the quantification of the intrapatient variability by showing the data distribution around the mean[0 measurements. We however, have chosen to use the mean absolute deviation (MAD) as a statistical measure for Tac IPV. Although the calculation of Tac IPV by means of MAD or CV are quite similar, the MAD is less susceptible to outliers. This is because the CV uses the squared deviation from the mean, whereas the MAD uses the absolute deviation[There are however several methods for the calculation of the fluctuation in Tac C the mean, 15. Ano the mean, 24–28. deviation, 11.0 are collected, is of greater importance and should be taken into account when interpreting Tac IPV data. And even though a great variation has been reported in literature, on average Tac IPV is between 15% and 30% which is in line with our findings[However, as stated above, the time period over which Tac C findings, 24–28.et al. were the first to establish an association between high intra-patient variability in Tac C0 and the increased risk of developing graft loss[Borra raft loss. Similarraft loss, 29–31. et al[2. They demonstrated a substantially smaller effect size of Tac IPV on long-term allograft outcomes after adjustment of the composite endpoint. Furthermore a majority of these studies focus on IPV over a brief time span in the first year after transplantation while chronic humoral rejection is usually diagnosed at an average of 4–6 years after transplantation.The current studies tend to rely on broad composite end-points consisting of a range of diagnoses such as late acute rejection, transplant glomerulopathy, graft failure and/or death with function–15. It cet al2. They dThe remainder of studies on this subject define non-adherence as self-reported drug-noncompliance, clinical suspicions by the attending physician and/or repeated nonattendance at clinic visits or laboratory testing, 14. Thiet al. where nonadherence was not significantly associated with late chronic active antibody mediated rejection[et al. observed that high IPV of Tac predicted chronic allograft damage such as tubular atrophy and severe fibrosis but not inflammation or transplant glomerulopathy lesions[In this study, IPV in cases and matched controls was similar and could therefore not support the hypothesis that a high IPV is associated with an increased risk for the development of chronic active antibody mediated rejection. These findings are in line with previous results published by Halloran rejection. Similary lesions.0 and renal function at starting point, the cases showed a significantly declining trend in both Tac C0 and renal function compared to the controls. The controls had a mean Tac C0 which varied around 6 ng/mL whereas the cases showed a gradual decline reaching Tac C0 of 5.4 ng/mL at endpoint. A similar development was visible in renal function where the controls showed an average decline in renal function of 1 ml/min/1.73m2 per year while the deterioration in graft function of the cases gradually increased to 10 ml/min/1.73m2 in the year prior to c-aABMR diagnosis. The decline in Tac C0 was significantly correlated to the decline in renal allograft function for the cases. Most likely, these observations reflect the physicians inclination to taper Tac dosage after witnessing a decline in allograft function, in an attempt to avoid presumed tacrolimus-related nephrotoxicity. Unfortunately, the entries made in the medical records were not sufficiently informative to support this conclusion with data.Although cases and controls in our study had similar Tac C0 seems to provide a better control of the chronic antibody mediated rejection which carries in general a poor prognosis for graft survival.Of interest is the significant association of an inferior graft survival for the c-aABMR patients with a high IPV versus those with a low IPV. This association was not found for the controls. This intriguing finding is in line with previous research suggesting poorer graft survival for patients with high IPV’s–15. The 0 were in range with what is considered common practice (6.1 ng/mL and 5.8 ng/mL).Our study does have several limitations. First, the causes of IPV cannot be determined due to the retrospective nature of the study. Even though multiple factors are known to contribute to a high IPV, nonadherence is considered a dominant cause, 16. SecIn conclusion, we demonstrated that a high intra-patient variability of tacrolimus long-term after kidney transplantation is not associated with the occurrence of chronic antibody mediated rejection but unfavorably affects graft survival in patients with c-aABMR.S1 File(SAV)Click here for additional data file.


To determine serum insulin-like growth factor 1 (IGF-I) levels in healthy Chinese adults, establish reference ranges for serum IGF-I levels and observe the effects of age, sex, body mass index (BMI) and geographical region on serum IGF-I levels.In total, 2791 healthy adults  from the north (Beijing) and south (Guizhou Province) of China were recruited following a questionnaire survey, physical examination and laboratory examination. Both sexes were divided into 13 groups according to age . The serum IGF-I levels were measured by performing a chemiluminescent assay (Immulite 2000®), and the LMS (Lambda-Mu-Sigma) method was applied to construct smooth centile curves of age-specific IGF-I levels.Serum IGF-I levels in the adults gradually decreased with increasing age from 18 to 70 years in both the male and female participants. Although the decrease in the level of IGF-1 was more pronounced in females than in males, no significant difference was observed between the sexes, except in the 60- to 64-year-old age group (P = 0.0329). The multiple linear regression model showed that there was an inverse relationship between the serum IGF-I level and BMI (P<0.001), and the serum IGF-I level in the Guizhou population was higher than that in the Beijing population (P<0.05).The normal reference ranges for age- and sex-specific serum IGF-I levels were established for the first time in a large sample of Chinese adults. The serum IGF-I levels were significantly influenced by age, BMI and geographical region. Insulin-like growth factor I (IGF-I) regulates cell proliferation. Human IGF-I was first discovered by Salmno and Daughaday in 1975 . Over 70Measurements of serum IGF-I are particularly useful in the diagnosis and management of patients with GH-IGF-I axis-related disorders, such as growth hormone deficiency (GHD) and excess GH secretion in children and adults. Moreover, serum IGF-I levels are used in dose adjustment for GH replacement therapy and have been considered the most reliable component for monitoring the effect of therapeutic interventions in acromegaly ,4.Juul et al. reported the reference ranges for adult serum IGF-I in Denmark in 1994 . SubsequTherefore, in our present study, we recruited a total of 2791 Han subjects from North and South China and measured their serum IGF-I levels using a chemiluminescent assay, which is widely used in both China and globally. Finally, this is the first study to establish the normal reference ranges for age- and sex-specific serum IGF-I levels in a large sample of Chinese adults. We found that the serum IGF-I levels gradually decreased with age in both sexes and that the serum IGF-1 levels correlated with the body mass index (BMI) and geographical region.This population-based study was conducted in North (Beijing City) and South (Guizhou Province) China between October 2009 and March 2012. A questionnaire survey, physical examination and laboratory measurements were performed to collect general information , medical history , physical parameters , urine parameters , blood parameters  (Siemens Advia 2120) and blood biochemical parameters  (OlympusAU5800). Information regarding the use of oral contraceptives was not collected.2, urine protein positive, any treatment for diabetes mellitus, pituitary gland hormone replacement therapy, and medical history); (2) subjects using potentially interfering medications, such as estrogen and corticosteroids; and (3) subjects with a BMI ≤18.5 kg/m2 or >28 kg/m2 who were defined as too thin or obese in the Chinese population, respectively.The exclusion criteria were as follow: (1) subjects with liver diseases, renal diseases, cancer, diabetes mellitus, diseases of the pituitary gland and pregnancy  were enrolled in the study. All subjects were divided into 13 groups according to age . The number of participants in each group is shown in This study was approved by the Ethics Committee of Peking Union Medical College Hospital (HS-1050). All participants provided written informed consent before participating in the study.All blood samples were drawn from the cubital vein between 8:00 a.m. and 9:00 a.m. after an overnight fast. The samples were collected in a BD vacutainer without any anticoagulation. The samples were then centrifuged at 3000 rpm for 15 min at 4°C, and the serum was transferred into Eppendorf tubes (2 ml). All samples were immediately frozen at -80°C until the measurements were performed. All samples were de-labeled; thus, individual participants could not be identified.th, 2016, and June 7th, 2016. The assay was calibrated against the WHO NIBSC 1st IRR 87/518 criteria before performing the measurements. The Immulite IGF-I control module provided by the manufacturer was used as the inter-assay control, which included IGF-I standard samples with low (62.3 ng/ml), middle (270.0 ng/ml) and high (575.0 ng/ml) concentrations. All inter-assay controls were within ±2 SD values as defined by the manufacturer  between April 12The construction of the centile curves was performed using the LMS method, which fits smooth centile curves to the reference data of age-specific serum IGF-I . This meThen, the centile could be calculated using The fit of the centile curves was assessed by a visual inspection comparing the empirical centiles with the LMS-generated curves. The goodness of fit test was conducted to compare the simulated centiles and measured centiles.The t-test and Wilcoxon signed ranks test were applied to analyze the influence of sex on the serum IGF-I levels and compare the difference between our results and those obtained by Elmlinger. A multiple linear regression model was also built to observe the influence of age, sex, BMI, geographical region, etc. on the serum IGF-1 levels. SAS /Insight module  and IBM 2, respectively. Age, BMI, TC, TG, and LDL in the males were all significantly higher than those in the females (P<0.01), while LDL and the fat % in the females were significantly higher than those in the males (P<0.01).The characteristics of all subjects are shown in The changes in the curves of the serum IGF-I levels with increasing age were drawn for the males, females and both sexes using the LMS method. As shown in th percentiles) of IGF-1 was 25.2 ng/ml higher in the 20–24 age group than that in the study by Elmlinger, and the lower limit reached similar levels in the 25–29 age group. After the age of 30, the IGF-1 levels in our study were lower until the age of 69 years. The maximum difference was 30.3 ng/ml in the 65–69 age group. Regarding the upper limit (97.5th percentiles), the IGF-1 levels in our study were significantly higher across all groups. The maximum difference was 70.5 ng/ml in the 20–24 age group. The IGF-I reference intervals (2.5th-97.5th percentiles) in our study ranged from 102.5 ng/ml to 288.3 ng/ml across the 20–69 age groups, while these intervals were 47.0 ng/ml to 158.0 ng/ml in the study by Elmlinger. Our data had statistically similar medians with Elmlinger’s.Next, we compared our present data with those obtained by Elmlinger in a study performed in a German population; these data were provided by the manufacturer and are used as the reference range in our daily clinical practice. As shown in The reference ranges for the serum IGF-I levels in our present study were compared with those in the study by Elmlinger using Wilcoxon signed ranks test. Both the lower and upper limits were significantly different (α<0.05).To compare the differences in the IGF-I levels between the sexes in each group, the SDS values of the serum IGF-I levels in each group were calculated using the LMS method and statistically analyzed using t-tests. As shown in The SDS serum IGF-I values in each group were calculated using the LMS method and compared by performing t-tests; the serum IGF-I levels in the males were significantly higher than those in the females only in the 60–64 age group (P = 0.0329).However, a significant sex difference was observed in the serum IGF-I levels between the males and females only at the age of 60–64 years (P = 0.0329), and the upper limit (+2 SD) and lower limit (-2 SD) in the males was 20.7 ng/ml and 19.1 ng/ml higher than that in the females, respectively.2 of the model was 0.416, and the standard error of the estimate was 62.6. The interacting item of BMI-age (multiply BMI by age) was introduced to eliminate the interaction effects between BMI and age. Consistent with the abovementioned results, the serum IGF-I levels were negatively correlated with age (P<0.001); the levels decreased by 4.5 ng/ml each year after adjusting for sex, geographical region and BMI. A regional distinction was also observed in this model, as evidenced by serum IGF-I levels in Guizhou that were 7.0 ng/ml higher than those in Beijing (P<0.01). With respect to BMI, all subjects were divided into quintiles , and the relationship between IGF-I level and BMI category was observed. The results showed that the IGF-I levels were significantly inversely associated with the BMI category. Subjects in a higher BMI category had lower serum IGF-I levels than those in a lower BMI category, and the average intra-group decrease was 16.6 ng/ml (P<0.001). Further analysis showed that the decrease in the serum IGF-I levels with age was 0.4 ng/ml lower in the subjects with a higher BMI when BMI and age were set as interacting variables (P<0.001). Finally, no significant differences were observed in the IGF-1 levels between the sexes, although the decrease in the females was steeper than that in the males (P = 0.855).Finally, a multiple linear regression model was established to observe the effects of age, sex, BMI, geographical region, etc. on the serum IGF-1 levels. As shown in th and 97.5th percentiles are also listed for clinical guidance. To the best of our knowledge, this was the first study to establish age- and sex-specific reference ranges for serum IGF-I on a large scale in a Chinese population using a chemiluminescent assay, and the sample size was also the largest in an Asian population.Accurate measurements of serum IGF-I levels and established reliable normative reference intervals are crucial for the diagnosis and treatment of disorders, including acromegaly (GH excess) and GHD (GH deficiency). However, normal reference ranges for serum IGF-I based on a large sample of the Chinese population are scarce. Therefore, in our present study, 2791 male and female Chinese subjects aged from 18 to over 70 years from North and South China were recruited, and the serum IGF-I levels were measured using a chemiluminescent assay. Subsequently, the serum IGF-I reference ranges and L, M, and S parameters of IGF-I were obtained in both sexes using the LMS method; the values of the 2.5It has been well documented that different commercial IGF-I assay kits could provide different results for the same samples with up to a 2.5-fold difference between the lowest and highest values . RadioimThe previous reference ranges for serum IGF-I provided by the IMMULITE 2000 manufacturer were obtained from a study conducted by Elmlinger in Germany in 2004 . In our In the present study, we demonstrated that the serum IGF-I levels in adults gradually decrease with age in both males and females. The serum IGF-I levels at the age of 45–49 years were approximately half of those at the age of 18 years and approximately one-fourth of those at the age of 18 years in subjects older than 70 years. The decrease in IGF-1 was steeper in the females, who initially had higher levels than the males but had lower levels than the males after the age of 50 years. However, the serum IGF-I levels in the males were significantly higher than those in the females only in the 60-64-year-old age group. Consistent with our observation, studies performed by Chanson et al. in a French population also demonstrated a continuous decline in circulating IGF-I levels throughout adulthood, which was accelerated in females compared with that in males . SimilarSex differences were observed in the serum IGF-1 levels in previous studies ,19,20. IBMI reflects both the body composition and nutritional status. Serum GH has been previously reported to be decreased and serum IGF-I has been reported to be increased in obese individuals . Fasting2 [However, several studies support the presence of a positive , non-lin2 . The mos2. Limited data regarding Asians have been reported. Probst-Hensch et al. [2 for males and 22.9 kg/m2 for females. Teramukai et al. [2. Our study provides valuable data regarding healthy subjects  with a broader age spectrum (18 to 87 years old). Notably, our study restricted the BMI (18.5–28 kg/m2). Our data may be more convincing if subjects with extreme BMIs (anorexia or adiposity) were included.Notably, most studies investigating the relationship between serum IGF-I and BMI were conducted in Western countries, where BMIs are usually over 24 kg/mh et al.  studied i et al.  studied Our study also found a geographical regional distinction in the serum IGF-I level, which has rarely been discussed in other studies. Bayram et al.  studied The reference values established in our study were constructed using the LMS method, which is one of the most widely applied approaches for age-related reference intervals. The LMS method was first proposed in 1988 by Cole. The parameters were estimated separately within each age group by maximum likelihood and then smoothed across age. This approach was adopted in our study for the following advantages. First, the distribution of serum IGF-I in the population was skewed, and the LMS method can produce convincing centile curves with skewed data. Second, the LMS method can draw any centile curve to perfectly meet the clinical needs. Third, the LMS method can calculate the SDS according to the measured values. Finally, the distribution of the curves constructed using the LMS method was dependent on the overall parameters, which could reduce the influence of grouping. The goodness of fit test is shown in Our study had several limitations. First, the assays were calibrated using the old standard IRP 87/518 rather than 02/254 as recommended since 2011 . TheoretIn conclusion, our study established age- and sex-specific reference ranges for serum IGF-I in a Chinese population and found that age, sex, BMI and geographical region all had a notable influence on the circulating IGF-1 levels. These results provide a foundation for the diagnosis and treatment of several diseases, including acromegaly and adult growth hormone deficiency in Asia.S1 FigThe intra-and inter-assay controls were made by ourselves. Serum with unknown IGF-I concentration were pooled together, then mixed thoroughly and dispensed into 47 Eppendorf tubes. When the measurements were conducted, these controls were evenly inserted into the sample sequence and were measured. The mean value was 216.7 ng/ml and the coefficient of variation (CV) was 3.0%.(DOCX)Click here for additional data file.S1 TableSubjects of both genders were divided into 13 groups according to the age . Each group contained more than 30 subjects except for the age group 19 .(DOCX)Click here for additional data file.S2 TableCV = coefficient of variation. Target values of low, middle and high concentration (mean ± SD) were 62.3 ±7.61 ng/ml, 270 ±26.7 ng/ml and 575 ±47.2 ng/ml, respectively. All the values were within ±2 SD values defined by the manufacturer.(DOCX)Click here for additional data file.S3 Tablevs females.TC = total cholesterol, TG = triglyceride, HDL = high-density lipoprotein, LDL = low-density lipoprotein, Fat% = body fat percentage. *P<0.01 (DOCX)Click here for additional data file.S4 TableDifference = (Simulated centile–Measured centile)/Measured centile.(DOCX)Click here for additional data file.


We find that in plasma, but not CSF, the bivariate MCP4 (CCL13)/ MCP1(CCL2) ratio is ca. twofold elevated in PTSD patients compared with healthy controls. The MCP-4/MCP-1 ratio is invariant over circadian time, and is independent of gender, body mass index or the age at which the trauma was suffered. By contrast, MIP-1β is a candidate biomarker for PTSD only in females, whereas TARC is a candidate biomarker for PTSD only in males. It remains to be discovered whether these disease-specific differences in circadian expression for these specific immune signaling molecules are biomarkers, surrogates, or drivers for PTSD, or whether any of these analytes could contribute to therapy.Post-traumatic stress disorder (PTSD) is psychiatric disease, which can occur following exposure to traumatic events. PTSD may be acute or chronic, and can have a waxing and waning course of symptoms. It has been hypothesized that proinflammatory cytokines and chemokines in the cerebrospinal fluid (CSF) or plasma might be mediators of the psychophysiological mechanisms relating a history of trauma exposure to changes in behavior and mental health disorders, and medical morbidity. Here we test the cytokine/chemokine hypothesis for PTSD by examining levels of 17 classical cytokines and chemokines in CSF, sampled at 0900 hours, and in plasma sampled hourly for 24 h. The PTSD and healthy control patients are from the NIMH Chronic PTSD and healthy control cohort, initially described by Bonne  The disorder is nearly always accompanied by profound difficulties in sleep.5 Some studies found chronic PTSD patients to have intrinsically low levels of circulating cortisol,7 suggesting a possible failure of feedback inhibition, leading to excessive levels of cell-mediated and proinflammatory cytokine expression.10 A recent candidate gene study showed that upstream drivers for PTSD include TNFα and the glucocorticoid receptor.11 Consistently, a recent study of plasma, taken hourly between 2000 and 0700 hours, showed that in civilian patients with chronic PTSD, cortisol levels are lower than in controls at the diurnal nadir, and shifted forward by ca. 2 h with rise towards a zenith cortisol levels merge at 0500 hours .7Post-traumatic stress disorder (PTSD) is a psychiatric disease that may occur following exposure to traumatic events.00 hours .7 The co12 However, comprehensive circadian studies in PTSD patients of either immune cells, or circulating immune mediators, are not yet available. Nonetheless, further implicating immune cell dysfunction in PTSD are studies showing suppressed gene expression in purified monocytes from blood samples, selected from a randomly chosen cohort of chronic PTSD patients from San Francisco.13 Similar conclusions have been drawn from studies of peripheral blood mononuclear cells, from blood samples from chronic PTSD cohorts of either holocaust survivors,14 or World Trade Center survivors.15 These data thus suggest that an experimental focus on immune cell mediators in PTSD plasma might provide robust biomarkers for this disorder.Circulating levels of immune cells, including monocytes, neutrophils and lymphocytes are regulated in a circadian manner, as are circulating levels of many of the cytokines and chemokines secreted by these and related cells.with MDD do have higher levels of serum interleukin-6 (IL-6) in samples taken at unspecified times,16 those PTSD patients without co-morbid MDD have serum IL-6 levels that are virtually identical to levels in normal controls.16 In addition, in a carefully controlled study of cerebrospinal fluid (CSF) from an NIMH cohort of civilian chronic PTSD patients relatively free from MDD, concentrations of Corticotrophin Releasing Factor (CRF), IL-6, brain-derived neurotrophic factor, IGF-1 and Substance P were found to be identical to levels in CSF from healthy controls.1 These results thus cast doubt on the involvement of some immune mediators in PTSD patients with limited comorbidities.Complicating this line of analysis, however, are reports that while PTSD patients who are co-morbid et al.7, as well as concurrent ACTH differences  and 11 non-traumatized, healthy subjects  matched to PTSD patients with respect to age, sex and body mass index (BMI), selected on the basis of availability of sufficient hourly plasmas and CSF, from the Bonne he study . Time elPsychiatric diagnoses were established using the Structured Clinical Interview for DSM-IV. The severity of PTSD was determined using the Clinician-Administered PTSD Scale (CAPS). Severity of depressive, anxiety and overall symptoms was assessed using the Inventory of Depressive Symptomatology (IDS), Hamilton Anxiety Rating Scale (HAMA) and Clinical Global Impression - Severity scale (CGI-S), respectively. Individuals with PTSD and controls did not differ with regard to age, gender distribution, race or BMI. Severity of PTSD was moderate, with a median CAPS score of 70 (range 54–95). Depression (IDS 16.4±8.2), Anxiety (HAMA 13.1±6.8) and overall symptom severity levels (CGI-S 4±1.2) were moderate as well.Participants were studied at the National Institutes of Health, under an institutional review board approved protocol. Lumbar puncture was performed between 0800 and 0900 hours by an experienced physician. A 20-gauge introducer needle was inserted and ~15 cc of CSF was withdrawn, centrifuged at 4000 r.p.m., and frozen in aliquots at −80°C for later assay. Four to 6 days after the procedure, participants had 27 hourly plasma sample drawings, beginning at 0700 hours and ending at 0900 hours the following day. Individuals were implanted with indwelling intravenous catheters. Nighttime sampling was done without disturbing participants. All blood samples were immediately anti-coagulated with sodium citrate, and the plasma collected by centrifugation. Following immediate centrifugation, the supernatant solutions were aliquoted, stored frozen at −80 °C, and reserved for later analysis.−1) was then added. The plates were once again sealed and set to shake at room temperature for 2 h. The plate was then washed once more in PBS+0.05% Tween-20. Read buffer was added at a 2 × concentration and the plate was read on the SECTOR 6000 Imager. Recently, the Human Chemokine 9-plex has been replaced with new reagents by the V-Plex. However, these studies were completed using the original Human Chemokine 9-plex, available (and recommended) by special order from the company.Two multiplexed assays for cytokines and chemokines were used for analysis of patient and control plasma samples on the SECTOR Imager 6000 instrument  The first of these assays was the Human ProInflammatory 9-Plex Assay for the measurement of IL-2, IL-8, IL-12p70, IL-1β, GM-CSF, IFN-γ, IL-6, IL-10 and TNF-α . The second of these assays was the Human Chemokine 9-Plex Assay for the measurement of Eotaxin 1, MIP-1β, Eotaxin-3, TARC, IP-10, IL-8, MCP-1 (CCL2), MDC and MCP-4 (CCL13) . The samples were added to plates that were pre-coated with capture antibodies for the specific cytokines. The plates was sealed and shaken at room temperature for 2 h. The plates were washed in PBS+0.05% Tween-20 and detection antibody solution . The 9-plex chemokine analysis for circadian plasma studies at 0900 and 0200 hours used the Bonferroni multiple correction criterion for significance . The Bonferroni multiple comparisons correction was not applied to 27-h circadian sampling, inasmuch as measurements were not independent, and provided that the proper levels of significance were attained at most, if not all, of the time points. Values for all analytes, measured at 0900 hours, for healthy controls, were mostly found to be statistically indistinguishable from data published by others who had also used the industry-standard MesoScale electrochemiluminescence Sector 6000 platform for analysis.20 Times were standardized to the sunrise time on the day blood sampling began . Circadian rhythms were modeled by fitting data to a cosine function.Accuracy of analyte measurements were assessed on the basis of reproducible technical replicates, low percentage coefficient of variation (CV<5%), presence within the linear portion of the standard curve, and a value above the lower limit of detection (LLOD). The differences between PTSD samples and normal controls were calculated using a two-tailed We also conducted tests to check for equality of the variances of the amounts of each analyte in the two groups, PTSD and healthy controls. When we applied these tests to the circadian changes in analyte serum levels, the variances were found to change by more than two fold over the 26 h study. Moreover, at different times the two groups oscillated as to which one had the larger variance. We attribute these changes in variance over circadian time to the fact that when the level of an analyte is at a plateau the variance reflects the intrinsic heterogeneity of the cohort. However, when the level starts to rise, or decline, each individual in the cohort starts at a slightly different time. Thus, the specific variances for both patients and healthy controls reflect both the heterogeneity of the individual average levels as well as the heterogeneity of the individual small time shifts. Thus, for those analytes where we find shifts in the time course between the patients and the control groups, the size as well as the order of the variances do change with time.Data were analyzed using a mixed model for repeated measures with group as a between-subjects factor, zeit as a within-subjects factor, and a subject random effect. Gender, BMI and age at trauma were included as covariates in some models.This approach allows for within-subject correlation without requiring complete data from every subject. Models were estimated using the MIXED procedure in SPSS version 22 .Z). The levels of each analyte were linearly interpolated between consecutive samples at whole 15 min Z intervals. In order to average results from multiple subjects, the interpolated analyte levels were converted to logarithmic values before averaging. Samples drawn more than 12 h after sunrise on the day of sampling are plotted as negative Z value, that is, at the respective time prior to the next day sunrise.The actual sunrise time on the date of sampling was used to convert the clock-time (T) of each sample withdrawal to the time relative to sunrise  is 0.82. By contrast, MCP-1 is reduced by ca. 20%. However, although the P-value for MCP-1 fails the significance test, the AUC value, 0.82, is the highest of all analytes. The MCP-1 and MCP-4 data thus stratify in opposite directions. We therefore tested the possibility that a significant multiparameter biomarker could be developed for PTSD from a ratio of the two values. Importantly, this strategy for disease-specific biomarker discovery has had recent successful precedence for Alzheimer disease21 and for temporal lobe epilepsy.17 As shown in the last row in P-value of 0.004, which survives a Bonferroni correction, and a high AUC value of 0.84. This PTSD-specific metric has a higher value at 0900 hours than 0200 hours (see below), indicating that the signal may be diurnal.On the basis of the fact that sampling of blood in a clinical setting would most likely occur in the morning, and in accordance with the time of the lumbar puncture, we initially analyzed the 0900 hours samples of plasma, collected according to local time. P=0.04; AUC=0.71); TNFα ; and IP-10 , they are relatively modest in effect size, and AUC values calculated from the receiver operation condition (ROC) curves are modest as well. Furthermore, our attempts to create candidate inversely directional classifiers from these elevated analytes with reduced MCP-1 resulted in less significant metrics than the one calculated from the MCP-4/MCP-1 ratio. Thus the MCP-4/MCP-1 ratio seems to be the best candidate biomarker for PTSD in the 0900 hours plasma.Several other individual cytokines and chemokines were also found to be significantly different in the PTSD 0900 hours plasmas compared with healthy control plasmas. These included IL-1β  even after accounting for multiple comparisons of nine chemokines. It is worth noting that there are also multiple time point comparisons performed. But since the distribution of p-values is such that each one of them is at, or close to, the Bonferroni criterion, there is no need to further account for them. Furthermore, when ratios at Z=7.75 are plotted as a ROC, the AUC is 0.879  h  h . Early mZ<12) h. However, Z<12) hours.Z=3) h). Entrainment differences for females (Z=−3) hours. Because of differences in numbers of females vs males in this study, the gender-independent analysis  hours, and at sunrise ((Z=0) h). PTSD males also have a novel peak at (Z=−3) h. The gender-independent differences become statistically insignificant because of the differences in direction of TARC levels in either gender (r gender . Thus plZ−7) and (Z+5) h. For PTSD patients, independent of gender, 100% of the populations have peaks at (Z+3) h. However, as shown in P-values (Z=0)). By contrast, there is virtually no difference between PTSD and healthy controls for Eotaxin. Furthermore, the entrainment analysis for IP-10 indicates that virtually all patients have a minimum at sunrise (Z=0). The value of these data for IP-10 and Eotaxin include not only the fact that they are unique in the literature, but that their entrainment amplitudes are exactly 12 h out of phase with each other.The complete circadian profiles for IP-10 , EotaxinP-values  show tha−1). In IL-8 entrainment studies, ca. 70% of both males and females show a broad peak in the region of (2<Z<9) hours, with evidence of a second peak at (9<Z<12) hours. Consistently, this double post-sun-up peak has been documented for IL-8 in the past.26In the case of IL-8, levels of IL-8 trend towards elevation in PTSD, but never reach significance. A second feature of the IL-8 distribution is that levels of IL-8 are higher in males (an average across circadian time of ca. 3.5 pg/ml) than in females  was 0.06. Surprisingly, we find that in the 0900 hours CSF samples, the MCP-4 and MCP-1 levels are the reverse of those found in plasma, and independent of PTSD. Specifically, in healthy control CSF, the MCP-1 levels are ca. 7-fold higher than in plasma, while the MCP-4 levels are ca. 100-fold lower. Furthermore, independently of the quantitative levels, the MCP-4/MCP-1 ratio in CSF does not significantly discriminate between PTSD and healthy control patients, as it does in the 0200 or 0900 hours plasma samples. Thus while the MCP-4/MCP-1 ratio appears to be a very good candidate biomarker for PTSD in plasma, it fails in CSF. Thus, the respective mechanisms responsible for setting CSF and plasma levels of MCP-1 and MCP-4 in PTSD and healthy controls appear to be independent of each other.vs controls, the difference in the MCP-4/MCP-1 ratio between PTSD and healthy controls remains highly significant , does not seem to have a significant effect on the MCP-4.MCP-1 ratio in the PTSD group . Finally, BMI  has no significant effect on the temporal behavior of the MCP-4/MCP-1 ratio either as a continuous variable (P=0.66) or as a categorical variable (P=0.36). This alternative mixed model approach to the analysis validates the analysis of variance approach used in other parts of this paper, and adds specific information on the lack of significant influence of the age of trauma on the circadian behavior of the PTSD-dependent MCP-4/MCP-1 ratio.By contrast, the age at the time of trauma, which we define as pre-pubertal Z – 6 h (about midnight) and sunrise time (Z=0). There is also trending evidence that the circadian rhythms for the MCP-1/MCP-4 ratio, MIP-1β and TARC may be shifted forward in time. These trends can be seen in entrainment plots of all three analytes for significant differences between PTSD and healthy controls in Z=ca. 9−12 h, circadian time . Importantly, plasma levels of three other chemokines  are not significantly affected by PTSD at any time, thus suggesting some specificity for those monocyte chemokines that distinguish PTSD patients from healthy controls.We conclude, based on both analysis of variance and mixed model statistical analyses, that the MCP-4/MCP-1 ratio in plasma is a significant, quantitative discriminator between PTSD patients and healthy controls. This effect is not significantly dependent on circadian time of day, gender, BMI or age in which the trauma is suffered. By contrast, the monocyte chemokine MIP-1β significantly distinguishes only between female PTSD patients and female healthy controls across the entire 27 h sampling period. However, in male PTSD patients, TARC, a lymphocyte chemokine released from monocytes, is significantly reduced only at 27 Both MCP-4 (CCL13) and MCP-1 (CCL2) share 67% sequence homology, and function as molecular attractants (‘chemokines') for monocytes, and to a lesser extent for lymphocytes and basophils. Both chemokines also share CCR2 as a common receptor.29 Therefore, the fact that the MCP-4/MCP-1 ratio, at any time, biomarks the plasma from PTSD patients can direct our attention to the existence of precedents for possible defects in monocytes and other immune cells associated with PTSD. Segman et al.14 studied peripheral blood mononuclear cells in survivors of terror attacks in Israel. Yehuda et al.15 studied whole blood expression patterns in survivors of the World Trade Center attack in New York. Neylan et al.13 studied purified CD14+ monocytes from men and women with PTSD and other comorbidities. In all three cases, a common observation was suppression of gene expression. The timing of blood collection is not mentioned in these publications, although morning collections might have been expected. Nonetheless, it remains a challenge to understand exactly how PTSD symptoms might correlate with dysfunctional gene expression in immune cells.It has been shown in animal models that an acute severe stressor can induce increased concentrations of inflammatory cytokines and chemokines, including MCP-1.25 In humans, nocturnal peak blood levels, encompassing the time period between 0100 and 0300 hours are observed for circulating monocytes, and for both T and B lymphocytes.12 Transcriptionally, nocturnal monocytes activate the expression of MCP-1.24 Beginning at ca. 0400 hours, levels of circulating monocytes, and both B and T cells, begin to decline.12 Coincidently, monocyte expression of MCP-1 is blocked by the transcription factors CLOCK, BMAL1 and EZH2.24 As predicted from this mechanism, MCP-1 plasma levels of healthy controls significantly drop from 0200 to 0900 hours by ca.70% (P=0.001) (P=2 × 10−6). This process is also seen in greater detail in the circadian pattern  . In the  pattern . It is tP=0.004), compared with a significant decrease of only ca. 40% in PTSD patients (P=0.01). This process is also seen in greater detail in the Z-corrected circadian pattern , MIP-1β  and TARC , but not other tested chemokines. Thus a central effect, consistent with previously published reciprocal changes in plasma cortisol and ACTH may be inferred.


The mini-clinical evaluation exercise (mini-CEX) is a well-established method of assessing trainees’ clinical competence in the workplace. In order to improve the quality of clinical learning, factors that influence the provision of feedback are worthy of further investigation. A retrospective data analysis of documented feedback provided by assessors using the mini-CEX in a busy emergency department (ED) was conducted. The assessors comprised emergency physicians (EPs) and trauma surgeons. The trainees were all postgraduate year one (PGY1) residents. The completion rate and word count for each of three feedback components  were recorded. Other variables included observation time, feedback time, the format used (paper versus computer-based), the seniority of the assessor, the gender of the assessor and the specialty of the assessor. The components of feedback provided by the assessors and the influence of these contextual and demographic factors were also analyzed. During a 26-month study period, 1101 mini-CEX assessments (from 273 PGY1 residents and 67 assessors) were collected. The overall completion rate for the feedback components was 85.3 % (positive feedback), 54.8 % (suggestions for development), and 29.5 % (agreed action plan). In only 22.9 % of the total mini-CEX assessments were all three aspects of feedback completed, and 7.4 % contained no feedback. In the univariate analysis, the mini-CEX format, the seniority of the assessor and the specialty of the assessor were identified as influencing the completion of all three components of feedback. In the multivariate analysis, only the mini-CEX format and the seniority of the assessor were statistically significant. In a subgroup analysis, the feedback-facilitating effect of the computer-based format was uneven across junior and senior EPs. In addition, feedback provision showed a primacy effect: assessors tended to provide only the first or second feedback components in a busy ED setting. In summary, the authors explored the influence of gender, seniority and specialty on paper and computer-based feedback provision during mini-CEX assessments for PGY1 residency training in a busy ED. It was shown that junior assessors were more likely to provide all three aspects of written feedback in the mini-CEX than were senior assessors. The computer-based format facilitated the completion of feedback among EPs. The mini-clinical evaluation exercise (mini-CEX) is a well-known reliable method of assessing trainees’ clinical competence in the workplace . The evaluations were conducted in the ED of Chang Gung Memorial Hospital (CGMH), a 3800-bed tertiary hospital in Taoyuan, Taiwan. This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital.The assessors comprised emergency physicians (EPs) and trauma surgeons. The trainees were all postgraduate year one (PGY1) residents. According to the regulations of the Ministry of Health, all medical students should have a 1-year rotation after graduation and before choosing their own specialty. In addition to emergency medicine, the one-year rotation curriculum also includes internal medicine, gynecology/obstetrics, pediatrics, general surgery, community medicine and a number of months in the specialty of their choosing. Each PGY1 resident received a curriculum of 1 week of trauma emergency training and 3 weeks of non-trauma emergency training during the one-month ED rotation. A total of 67 assessors (50 EPs and 17 trauma surgeons) evaluated 273 PGY1 residents during their emergency medicine training.The data was collected between November 2009 and December 2011. The mini-CEX used was in a traditional Chinese format that has been previously validated . Alpha was set at p < 0.05.We analysed the mean age of patients, the seniority of the assessor, the observation time, the feedback time, the gender of the assessor, the specialty of the assessor, the completion rate of each domain of clinical competency, the word count (in Chinese) used for feedback on each component, and the impact of the format used on the provision of all three aspects of feedback. We also analyzed the frequency of use for each feedback component , of all feedback components and of no feedback for weekly mini-CEXs. When comparing results between two groups, where appropriate, a A total of 1101 mini-CEX ratings of PGY1 residents were completed during the study period. During the study period, EPs rated 899 PGY1-patient encounters and trauma surgeons rated 202 PGY1-patient encounters. The EP-rated mini-CEXs comprised 295 paper-format evaluations and 604 computer-format evaluations. The overall completion rates for the components of positive feedback, suggestions for development and agreed action plan were 85.3, 54.8, and 29.5 %, respectively. Only 22.9 % of the total mini-CEXs contained all three components of feedback, while 7.4 % of mini-CEXs were without any feedback.Feedback was provided on 878 (97.7 %) mini-CEXs rated by emergency physicians and on 142 (70.3 %) mini-CEXs rated by trauma surgeons. Using the paper format of the mini-CEX in the ED, the feedback time was longer when PGY1 residents were rated by trauma surgeons than when they were rated by EPs  were higher for the EP group: 89.2, 57.0 and 28.1 %, respectively when provided by EPs; and 67.3, 33.2 and 12.9 %, respectively when provided by trauma surgeons. Feedback containing all three components was provided on 19.0 % of the assessments by EPs and on 12.4 % of those completed by trauma physicians. Only 5.1 % of assessments completed by EPs, but 29.7 % of those by trauma surgeons, provided no feedback at all.After a computer-based mini-CEX was implemented, EPs were requested to complete mini-CEXs in this format. The computer-based format contained exactly the same components as the paper-based format. The mean age of patients, observation time, feedback time and gender of the examinees were similar for both formats. However, the seniority of the assessor was greater and a higher proportion of men were in the group using the paper-based format. As it was decided that PGY1 doctors would be free to choose their assessors in the clinical placement setting, a selection bias could have resulted due to their choices.p < 0.001 and 93.9 vs. 99.3 %, p < 0.001, respectively). Clinical skills were evaluated more often using the paper-based format than using computer-based format (48.8 vs. 11.9 %). The difference between clinical skills’ results and other results is related to the interference of the implementation of direct observation of procedural skill (DOPS), which explained the reduction in the frequency of assessing technical skills in the mini-CEX. Therefore, it made no sense to compare the completion rates for the clinical skill assessment across the paper- and computer-based different formats.In the clinical domain of competency, efficiency/organization and professionalism were evaluated more often using the computer-based format than using paper-based format , while more feedback was provided using the computer-based format than paper-based format for agreed action plans . Feedback containing all three components was provided by 28.3 % of the mini-CEXs using the computer-based format and 19.0 % of mini-CEXs using the paper-based format  when using the computer format. Two of the feedback components, suggestions for development and an agreed action plan, were also used significantly more often by junior EPs than by seniors  than did seniors -based formats  explains a reduction in the frequency of assessing technical skills in the mini-CEX. Therefore, it made no sense to compare the completion rate of clinical skill assessment using different formats. Finally, it is very likely that some of the communication between trainees and assessors was not documented in the mini-CEX form; further investigation is needed to evaluate the gap between verbal feedback and written feedback.Our study analyzed the provision of feedback in mini-CEX assessments during PGY1 resident ED rotations. Junior assessors were more likely to provide all three aspects of feedback than were senior assessors. A computer-based format facilitated the completion of feedback, especially on the part of junior assessors among EPs. Additional studies are needed to qualitatively analyze differences and to consider the effects of computer-based formats used by other specialized doctors.


Furthermore, the intrinsic MgZnO film is deposited as the absorption layer for the metal-semiconductor-metal ultraviolet photodetectors (MSM-UV-PDs) using the vapor cooling condensation system. The 100-nm-linewidth nanomesh electrodes with metal occupying a roughly 10% of the device surface region consequently render PDs with a high transmittance in the ultraviolet (UV) wavelength range. The photoresponsivity of MgZnO-based MSM-UV-PDs evaluated at the wavelength of 330 nm with the operating bias voltage of 5 V is elevated from 0.135 to 0.248 A/W when the thin metal electrode is replaced by the nanomesh electrode, and the corresponding quantum efficiency is improved from 50.75 to 93.23%. Finally, adopting the nanomesh electrode also helps to enhance the UV-visible rejection ratio (R The ultraviolet photodetectors (UV-PDs) have been widely employed in inter-satellite communications, ozone monitoring, missile detection, flame sensor, and chemical/biological analyzer1246911130.25Zn0.75O powder in the tungsten boat is allowed to cooled and condensed on the Ti/Ni metals152 isolation layer is then grown using a radio-frequency magnetron sputter system. The shadowing mask derived from the nanosphere lithography technique is used to realize the nanomesh electrodes. o, the deposited nanomesh structure is gradually discontinuous due to the excessive nanosphere cast shadows. To avoid breaking the electrical properties of nanomesh electrodes, the incident angle in the fabrication of the nanomesh electrode is fixed at 40o. Besides, the polystyrene nanospheres of various sizes are utilized to control the density of the nanomesh structure in the oblique deposition processes. After removing the redundant Ni/Au metals with a lift-off process, the nanomesh electrodes are realized. 2.To compare the performances of MgZnO-based MSM-UV-PDs with and without the nanomesh electrode, the transmittance and the sheet resistances are measured using the UV-VIS-NIR spectrophotometer and the four-point probe resistivity measurement, respectively. The transmittances of the quartz covered with 5 nm/5 nm (#1TM), the 5 nm/10 nm (#2TM), and the 5 nm/15 nm-thick (#3TM) Ni/Au metals and measured at a wavelength of 330 nm are 42.5%, 34.9%, and 29.3%, respectively. In general, the metal films thinner than 20 nm are aggregated as the island-like structure, and the light penetrates through the hollow portiond-V) characteristics of the MgZnO-based MSM-UV-PDs with the #1TM, #2TM, and #3TM metal electrodes measured by the Agilent 4156C semiconductor parameter analyzer. The major influence on the dark Id-V is the sheet resistance of the thin metal electrodes, because the same MgZnO-based MSM-UV-PDs structure is utilized except the illuminated electrodes. The smaller grain size and the larger interval among the grains in the island-like structure of the thin metal film are formed with decreasing the metal film thickness, which causes a rapid increase in the sheet resistance. The resultant measurements demonstrate that a decrease in the dark current is accompanied with an increase in the sheet resistance of the thinner metal electrodes. 330nm/R450nm) are also listed in d-V) characteristics of the MgZnO-based MSM-UV-PDs with the #1NM, #2NM, #3NM, and #4NM nanomesh electrodes as measured by the Agilent 4156C semiconductor parameter analyzer. For the MgZnO-based MSM-UV-PDs with the nanomesh electrodes, the dark current increases as result of the nanomesh spacing reduction, which is attributed to the higher metal coverage ratio and the lower sheet resistance. Besides, compared to the nanomesh electrodes, the MgZnO-based MSM-UV-PDs using the #2TM metal electrode reveal the lower dark current due to their higher sheet resistance. However, the photoresponsivity performance is reduced by the higher sheet resistance from the islands-like structure of the thin metal electrode as mentioned above. 330nm/R450nm) of 2480 are obtained for the MgZnO-based MSM-UV-PDs using the #3NM nanomesh electrode. The highest quantum efficiency and UV-visible rejection ratio are attributed to a better trade-off between the shadowing effect and the electrical characteristic of the #3NM nanomesh electrode. Moreover, although the #3NM nanomesh electrode structure has a longer carrier transportation path on the MSM-UV-PDs due to the less metal coverage ratio compared with the #2TM metal electrode structure. However, the enhancement of 84% in the photoresponsivity of the MgZnO-based MSM-UV-PDs using the #3NM nanomesh electrode is still achieved owing to the improvement of 156% in the transmittance compared with that of #2TM metal electrode structure, and the higher quantum efficiency and the higher UV-visible rejection ratio of the MgZnO-based MSM-UV-PDs using the #3NM nanomesh electrode are therefore obtained.As presented earlier, the MgZnO-based MSM-UV-PDs using the #2TM metal electrode and the #3NM nanomesh electrode both achieve the highest performance benchmarks when compared to similar PDs with the other types of thin metal electrodes and the nanomesh electrodes. n > is the total noise current and R was the photoresponsivityn > 2 values extracted for the MgZnO-based MSM-UV-PDs using the #2TM metal and the #3NM nanomesh electrodes are 1.85 × 10−21 A2 and 3.34 × 10−21 A2, respectively. Moreover, as also listed in −10 W and 2.33 × 10−10 W. The detectivity (D*) can be expressed as:2 is the optical sensing area of the photodetectors and 10 cmHz0.5W−1 and 2.43 × 1010 cmHz0.5W−1, respectively. The lower NEP and the higher D* for the MgZnO-based MSM-UV-PDs using the #3NM nanomesh electrode are attributed to a significantly reduced shadowing effect without compromising the electrical property of the electrodes. According to the experimental results gathered, the superior detection performances of the nanomesh electrodes are hereby verified.The noise equivalent power (NEP) is rightly expressed as 10 cmHz0.5W−1 to 2480 and 2.43 × 10  cmHz0.5W−1. The transmittance and the sheet resistance of the #3NM nanomesh electrode are 89.3% and 61 Ω/⬜, respectively. According to the experimental results, the nanomesh electrode with the narrower linewidth and the smaller mesh spacing significantly reduce the shadowing effect, while it does not debase the carrier extraction capability of MgZnO-based MSM-UV-PDs at the same time. Therefore, it is emphatically demonstrated that the nanomesh electrode has presented itself as a promising candidate for device applications involving MSM-UV-PDs.The nanosphere lithography technique and the oblique evaporation method have been used to fabricate the 100-nm-linewidth nanomesh electrodes patterned on the MgZnO-based MSM-UV-PDs, because the oblique evaporation has the larger nanosphere cast shadows than that of the conventional vertical evaporation. The 100-nm-linewidth nanomesh metal electrode exhibits a high transmittance and a low sheet resistance. The thin metal electrodes are also fabricated on the MgZnO-based MSM-UV-PDs using the same fabrication processes for comparison. To investigate the mesh spacing dependence on the performance of the MgZnO-based MSM-UV-PDs, the mesh spacing of the nanomesh electrode is precisely controlled by using the various-size nanospheres. In general, the wider nanomesh spacing implies the worse electrical properties including the higher sheet resistance, the longer carrier transportation path, and the smaller induced electrical field, but it has the higher optical transmittance. Considering the inherit trade-off relation between the electrical property and the optical property, the suitable nanomesh electrode for the MgZnO-based MSM-UV-PDs in this study is carried out. Consequently, the photoresponsivity and the quantum efficiency are respectively improved from 0.135 A/W and 50.75% to 0.248 A/W and 93.23% when the thin metal electrode is replaced by the nanomesh electrode. The corresponding UV-visible rejection ratio and the detectivity are also enhanced from 1663 and 1.78 × 10To fabricate the nanomesh electrode, the polystyrene nanospheres have been utilized as the shadowing mask. The polystyrene nanospheres are uniformly mixed in a surfactant Triton X-100: methanol (1:400) in order to obtain a 5 wt% polystyrene nanosphere solution, and the spin-coating method is then used to form the monolayer hexagonal close-packaged structure of the polystyrene nanospheres. The polystyrene nanosphere array is first spun coated on the MgZnO absorption layer with the spinning speed of 300 rpm for 30 sec and then with the spinning speed of 3000 rpm for 60 sec. The polystyrene nanosphere mask is then patterned afterward.o. The oblique evaporation ultimately renders a higher shadowing effect, which in turn helps to reduce the linewidth of nanomesh electrodes.In this work, the oblique evaporation method is used to reduce the metal coverage ratio of nanomesh electrodes. The Ni/Au (20 nm/100 nm) metal films are obliquely deposited through the polystyrene nanosphere mask using the nanosphere lithography technique in order to realize the nanomesh electrodes. How to cite this article: Lee, C.-T. et al. Nanomesh electrode on MgZnO-based metal-semiconductor-metal ultraviolet photodetectors. Sci. Rep.5, 13705; doi: 10.1038/srep13705 (2015).


We described the incidence of stroke in HF-PEF patients with and without AF and predictors of stroke in those without AF.The incidence and predictors of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), but c-index 0.71, 95% confidence interval 0.57–0.84 vs. 0.73, 0.59–0.85, respectively) as the predictive variables overlapped. The model performed well in the validation cohort . The rate of stroke in patients in the upper third of risk approximated to that in patients with AF .We pooled data from the CHARM-Preserved and I-Preserve trials. Using Cox regression, we derived a model for stroke in patients without AF in this cohort and compared its performance with a published model in heart failure patients with reduced ejection fraction (HF-REF)—predictive variables: age, body mass index, New York Heart Association class, history of stroke, and insulin-treated diabetes. The two stroke models were compared and Kaplan–Meier curves for stroke estimated. The risk model was validated in a third HF-PEF trial. Of the 6701 patients, 4676 did not have AF. Stroke occurred in 124 (6.1%) with AF and in 171 (3.7%) without AF . There was no difference in performance of the stroke model derived in the HF-PEF cohort and the published HF-REF model (A small number of clinical variables identify a subset of patients with HF-PEF, but without AF, at elevated risk of stroke. Up to half of patients with heart failure have a preserved ejection fraction (HF-PEF).5 and the Irbesartan in Heart Failure with Preserved Systolic Function trial ,without AF in this pooled dataset. Easy identification of those at highest risk of stroke coupled with the availability of new oral anticoagulants with a low risk of bleeding might allow for a stroke prevention strategy which has an acceptable benefit/risk balance in patients with HF without AF.To investigate this further, we therefore combined and analysed patient-level data from two large HF-PEF trials, the Candesartan in Heart failure Assessment of Reduction in Mortality and Morbidity-Preserved trial ,In order to have a sufficiently large number of HF-PEF patients without AF for analysis, we pooled data from the CHARM-Preserved (NCT00634712) and I-Preserve (NCT00095238) trials. Each was a randomized, double-blind, placebo-controlled, multicentre trial and was approved by the appropriate institutional review boards. CHARM-Preserved and I-Preserve enrolled 3023 and 4128 patients, respectively.,,,CHARM-Preserved enrolled patients aged ≥18 years in New York Heart Association (NYHA) functional class II–IV with a left ventricular ejection fraction (LVEF) >40% . I-Preserve enrolled patients aged ≥60 years in NYHA functional class II–IV with an LVEF ≥45% and corroborating ECG, echocardiographic or radiologic evidence. In addition, patients must have been hospitalized for heart failure in the preceding 6 months or, if not, had to be in NYHA functional class III or IV. N-terminal pro B-type natriuretic peptide (NT-proBNP) was measured at baseline in I-Preserve but not in CHARM-Preserved. In CHARM-Preserved, patients were randomly assigned to candesartan (target dose of 32 mg once daily) or matching placebo.,,,,,,Incident strokes were centrally adjudicated by an independent endpoint committee in each trial using similar definitions and stroke was part of the primary or secondary composite cardiovascular outcomes in both trials.The occurrence of AF was retrospectively collected in CHARM-Preserved during the trial close-out using a specifically designed case-report form. Incident AF was recorded prospectively in I-Preserve, using a specific case-report form.We included only patients with an LVEF of ≥45% . Patients with AF were defined as those with either AF confirmed on their baseline ECG or a history of AF. The remaining patients were defined as those ‘without AF’. Descriptive statistics were used to describe the pooled patient population from both trials and to compare these two subgroups, using means (standard deviation) or medians [inter-quartile range (IQR)] for continuous variables and count (percentage) for categorical variables.The incidence rate of stroke (per 100 patient-years) was calculated over the trial follow-up period and was compared among the AF and no AF subgroups. We plotted Kaplan–Meier (KM) curves for the occurrence of stroke, according to AF status. To satisfy the assumption of the independence of stroke events, recurrent stroke events in a patient after randomization were not included in the analysis.–P < 0.05) in univariable analysis of our dataset. The final list of variables included was age, sex, LVEF, NYHA class III/IV, BMI, creatinine level, systolic blood pressure, history of stroke, hypertension, and diabetes treated with insulin. Second, we applied a recently published multivariable predictive model for stroke in patients with HF-REF (HF-REF stroke model) in our HF-PEF cohort.2 statistic. In order to be consistent with our previous publication,c-index for the Cox regression models according to the method of Pencina and D’Agostino,et al.c-indexes for the two models were not meaningfully different.Continuous variables  were assessed by visual inspection of restricted cubic splines to identify potential non-linear effects. Uni- and multivariable predictors of the risk for stroke were evaluated using Cox proportional hazards regression analysis in patients without AF. Two separate multivariable analyses for stroke were created. First, an ‘HF-PEF stroke model’ was created using established predictors of ischaemic strokeThe coefficients from statistically significant variables in the final multivariable model were used to calculate an individual patient’s risk score for stroke. The KM curves for occurrence of stroke according to tertiles of risk score were plotted.c-index.,Final model calibration and the ability to separate patients into risk groups were assessed by observing predicted compared with observed outcomes in terciles, and by using the Hosmer–Lemeshow goodness-of-fit test. The model’s discrimination abilities were evaluated by the overall ,c-index of the model with the traditional Harrell’s c-statistic.We also conducted a sensitivity analysis to compare the cumulative incidence function for stroke estimated using competing risk technique (to account for the competing risk of death)Finally, we validated the preferred risk model in a third HF-PEF trial: the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) (NCT00094302).All analyses were undertaken using SAS version 9.3 .Of the 6701 patients with an LVEF ≥45%, 2025 (30%) had a history of AF or AF on their baseline ECG and 4676 patients (70%) had no AF.Table The baseline characteristics of patients with and without AF are shown in the without AF were younger and were more likely to have a history of coronary artery disease and hypertension, compared with patients with AF. Patients without AF also had a slightly higher systolic blood pressure but had a lower mean serum creatinine and much lower median NT-proBNP level than patients with AF. There were also notable differences in medical therapy, particularly in use of antiplatelet therapy (69% of patients without AF vs. 39% of those with AF) and anticoagulant treatment , but also in relation to diuretics, mineralocorticoid receptor antagonists, antiarrhythmic agents, and digoxin.Patients Among patients without AF, those who experienced a stroke (compared with those who did not) were older, more likely to have a history of diabetes, hypertension, and stroke and had worse NYHA functional class. Patients experiencing stroke also had a higher systolic blood pressure, creatinine, and NT-proBNP level. Compared with those not experiencing stroke, those who did were less likely to be treated with lipid lowering therapy but more likely to be taking nitrates, anti-platelet therapy, and insulin. Very few patients in either group were treated with an oral anticoagulant . LVEF did not differ between patients with and without stroke.Figure FigureS1).The median follow-up time in patients with AF was 3.4 (IQR: 2.8–4.4) years and 124 of these 2025 patients (6.1%) experienced a stroke (1.80 per 100 patient-years). The 1, 2, and 3 year KM rates for stroke were 1.5 (95% CI: 1.0–2.1)%, 3.5 (95% CI: 2.7–4.4)%, and 5.5 (95% CI: 4.5–6.6)%, respectively  years and 171 of these 4676 patients (3.7%) experienced a stroke (1.00 per 100 patient-years). The 1, 2, and 3 year KM rates of stroke were 1.0 (95% CI: 0.8–1.4)%, 2.0 (95% CI: 1.7–2.5)%, and 3.0 (95% CI: 2.5–3.5)%, respectively  experienced a stroke. Of these 59 patients, 10 (17%) developed new AF before the occurrence of their stroke; the number of patients with a stroke without preceding AF was 49 (83%). Development of AF reported was not reported in any patient following a stroke.In I-Preserve, 2895 patients did not have AF at baseline. Out of 2895, 112 patients (4%) experienced a stroke. Of these 112 patients, 18 (16%) developed new AF before the occurrence of their stroke; the number of patients with a stroke without preceding AF was 94 (84%). Twenty patients (18%) with an incident stroke had new AF reported before or after their stroke.Figure TableS2 show the relationship between baseline variables and risk of stroke . TableS3 shows an adjusted analysis using the four independent predictors identified in a multivariable stroke model developed in the present HF-PEF cohort . These overlapped with the five independent predictors in the HF-REF stroke model  (Table c-index for the HF-PEF model was 0.71 (95% CI: 0.57–0.84) compared with 0.73 (0.59–0.85) using the HF-REF model . Thus, we proceeded using the previously validated HF-REF model. This model can be used to calculate an individual’s risk of stroke as described in the Supplementary material.Figure Figure Figure Figure P = 0.761.We tested the predictive model in TOPCAT, which included 1240 patients with and 2205 patients without AF. The mean follow-up was 3.5 years. There were 65 strokes in the patients with AF and 52 strokes in those without AF, giving stroke rates in patients with and without AF 1.64 and 0.71 per 100 patients-years, respectively.TableS4, FiguresS2andS3), the 1, 2 and 3 year KM rates of stroke in patients without AF, in the two higher risk tertiles were: tertile 2: 1.3 (95% CI: 0.6–2.4)%, 1.3 (95% CI: 0.6–2.3)% and 1.7 (95% CI: 0.9–2.9)%, respectively; and tertile 3: 1.5 (95% CI: 0.8–2.7)%, 1.7 (95% CI: 0.9–2.9)% and 2.6 (95% CI: 1.6–4.1)%, respectively. Patients in risk-tertile 3 of the validation model derived from TOPCAT cohort had an overall stroke rate of 1.06 per 100 patient-years. The overall c-index for the model was 0.86 (95% CI: 0.62–0.99).Using the same analytical approach .In this analysis, HF-PEF patients without AF in this study had a lower risk of stroke compared with those with AF. However, the overall rate of stroke in HF-PEF patients without AF (1.0% per year) was similar to the rate we recently reported in HF-REF patients without AF (1.2% per year). Moreover, as in HF-REF, a small number of demographic and clinical variables identified a subset of HF-PEF patients without AF who were at greater risk of stroke than the remainder. Specifically, in our pooled analysis, patients in the upper third of the risk score had a rate of stroke (1.6% per year) which was higher than in HF-PEF patients with AF receiving an anticoagulant (1.5% per year), although not as high as in similar patients not treated with an anticoagulant (2.2% per year).HF-PEF patients without AF although in patients in the same age range in clinical trials for hypertension (i.e. with a similar co-morbid phenotype to HF-PEF) have a stroke risk of around 1% per year or less.with AF randomized to warfarin in ARISTOTLEWe have been unable to find other reports of the risk of stroke in HF-PEF patients without AF, is also of interest. We previously reported that LVEF was not predictive of stroke in HF-REF patients without AF. Neither was LVEF an independent predictor of stroke risk in this study although we examined only patients with an LVEF ≥45%. This finding is consistent with observations in three recent trials comparing non-Vitamin K antagonist oral anticoagulants with warfarin in patients with AF. In those trials, the risk of stroke and systemic embolism was similar, irrespective of LVEF category, in patients with AF and concomitant HF. A similar conclusion was reached by the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE) in AF patients not treated with an oral anticoagulant where the risk of stroke was similar in patients with concomitant HF-REF or HF-PEF.The similar risk of stroke in patients with HF-PEF and HF-REF, As in HF-REF, we found that neither systolic blood pressure nor history of hypertension was independent predictor of stroke. Although this contrasts with the findings in other patient cohorts, it is consistent with the ‘reverse epidemiology’ of heart failure and the known association between higher blood pressure and better outcomes in this condition.potentially to justify anticoagulation. Clearly, there is as yet no trial evidence to justify such treatment but our findings suggest a means of identifying patients for such a trial. Consistent with this hypothesis, prior trials in patients with heart failure and reduced ejection fraction collectively suggest that anticoagulation can reduce the risk of stroke in patients in sinus rhythm. However, in the largest of these, the Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction trial (WARCEF), although warfarin was effective in reducing ischaemic stroke this benefit was offset by major bleeding. With non-vitamin K oral anticoagulants, the risk-to-benefit balance might be more favourable, especially as the target International Normalized Ratio (INR) in WARCEF was 2.75 (range 2.0–3.5).A particular strength of this study is the validation of our predictive model in another dataset (TOPCAT). Consequently, our findings have clear clinical implications. With a small number of routinely collected clinical variables it is possible to identify patients with HF-PEF, but without AF, who may be at sufficiently high risk of stroke Each of the two trials included had specific inclusion and exclusion criteria and, hence, our findings may not be generalizable to all patients with HF-PEF. Notably, few patients were in NYHA class IV and worse functional class was a predictor of higher risk of stroke. Hence, the risk of stroke may be higher in ‘real world’ patients than in the cohort studied. Although our data suggest that only the minority of strokes is related to incident AF, systematic detection of new onset AF was insensitive, e.g. continuous ambulatory monitoring was not performed. It is widely recognized that silent AF is frequent in heart failure and undetected AF may have accounted for more strokes than realized. However, waiting for the development of clinically recognized AF before employing anticoagulant therapy may not be the ideal preventive strategy and the best and most cost-effective way to screen for silent AF in HF-PEF is unknown. In addition, these patients may have other reasons to develop thromboembolic and other types of ischaemic stroke, e.g. endothelial dysfunction and blood stasis. Therefore, we believe that our findings support a potential preventive role for anticoagulant therapy in HF-PEF patients in sinus rhythm, particularly as new agents with a lower risk of bleeding are available. Of course, this hypothesis needs to be tested prospectively in a randomized trial and it may be too simplistic to assume that an anticoagulant can substantially reduce the risk of stroke in those with HF-PEF at highest risk.CHARM-Preserved and I-Preserve were randomized controlled heart failure trials, rather than stroke trials, and used definitions of stroke consistent with other heart failure trials conducted during the same period. Although the definition may not be identical to that used in contemporary stroke trials, it was applied consistently by adjudicators blind to treatment allocation and thus gave an unbiased estimate of treatment effect. Unfortunately, classification of stroke subtype was not carried out in both trials. When the trials were conducted, neuroimaging was not standard in patients with suspected stroke in many, if not most countries, involved. Therefore, we are unable to distinguish between ischaemic and haemorrhagic strokes.without AF have a risk of stroke similar to that in HF-PEF patients with AF. This higher-risk subset can be identified using five simple clinical variables. The risk of stroke is similar in HF-PEF and HF-REF patients without AF and is predicted by the same variables. The risk of stroke in these patients might be reduced by treatment with an oral anticoagulant but this hypothesis needs to be tested in a clinical trial. The rate of stroke in the highest risk tertile was not quite as high as in patients with AF not treated with an anticoagulant so it is uncertain what the benefit/risk ratio of such treatment might be.In conclusion, we found that a relatively high-risk subset of a third of HF-PEF patients European Heart Journal online.A.H.A.R., A.C.P., R.L.M., and B.L.C. performed the statistical analysis; J.J.V.M. and K.R.L. handled funding and supervision; J.J.V.M. and A.H.A.R. conceived and designed the research, and drafted the manuscript; all co-authors made critical revision of the manuscript for key intellectual content.A.H.A.R. received departmental funding to perform the analysis. A-CP was supported by the Medical Research Council award MC_UU_12017/10.Conflict of interest: K.R.L. chairs the Data and Safety Monitoring Board for the RESPECT-ESUS Trial, sponsored by Boehringer Ingelheim. G.Y.H.L. is a consultant for Bayer/Janssen, Astellas, Merck, Sanofi, BMS/Pfizer, Biotronik, Medtronic, Portola, Boehringer Ingelheim, Microlife and Daiichi-Sankyo, and he is a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche and Daiichi-Sankyo. The other co-authors declared no conflict of interest.Supplementary DataClick here for additional data file.


High-voltage electricity lines are known to generate extremely low-frequency electromagnetic fields (ELF-EMFs). With the process of urbanization, increasing concerns has been focused on the potentially hazardous impacts of ELF-EMF on human health, and the conclusions are controversial. Little is known about the method of prevention against ELF-EMF induced healthy problems. A total of 186 male workers with occupational exposure to high-voltage electricity lines, and 154 male subjects with insignificant exposure as reference control were enrolled in this study. Resveratrol or placebo was given as dietary supplements (500 mg twice daily), and several inflammatory biomarkers and biomarkers of oxidative stress were assessed. Workers who had long-term exposure to high-voltage electricity lines exhibited elevated urinary levels of 8-hydroxy-2-deoxy-guanosine (8-OHdG) and F2-isoprostane, compared to the reference group. Lower plasma nuclear factor kappa B (NF-κB) and interleukin (IL)-6 were observed in exposed workers compared to the reference group. Resveratrol significantly reversed the adverse impacts of ELF-EMF. Stimulated cytokine production by resveratrol was found in exposed workers but not in the reference group. This study supported that occupational and long-term exposure to high-voltage electricity lines has an adverse effect on homeostasis of human body, and resveratrol supplement could be an effective protection strategy against the adverse effects induced by ELF-EMFs. High-voltage electricity lines are known to generate extremely low-frequency electromagnetic fields (ELF-EMFs). Since 1970, a number of researches have investigated the potentially hazardous impacts of ELF-EMFs on human body but the conclusions remain controversial .in vitro study, and it was correlated with enhanced neurotoxin 1-methyl-4-phenylpyridinium (MPP) in Parkinson's disease [via inducing anti-inflammatory state, increasing endothelial cell proliferation and stimulating collagen formation [A study on human osteosarcoma MG-63 cells indicated that ELF-EMF may induce cell apoptosis through impairing redox homeostasis and activating the p38 mitogen-activated protein kinase (MAPK) [ disease . On the ormation . The invEpidemiological investigations showed that ELF-EMFs was a possible risk factor for acute myeloid leukemia and follicular lymphoma among workers with occupational exposure . ELF-EMFex vivo stimulation of interleukin (IL)-6, IL-8, IL-1β and tumor necrosis factor-alpha (TNF-α) was performed. Previous studies have demonstrated the biochemical and physiological functions of resveratrol, including protective effects against cardiac oxidative stress and alleviation of inflammation [In this study, we aimed to analyze the effects of occupational ELF-EMF exposure on several inflammatory biomarkers and biomarkers of oxidative stress. Additionally, ammation , 12. As To eliminate the influence of variants on the outcomes of this study, we selected the participants with similar age and BMI ranges. After inclusion and exclusion Table , the remTable Compared to placebo  and 2, dex vivo stimulated production of IL-6, IL-8, IL-1β and TNF-α by LPS  was worsened by TLR stimulation and therefore inhibit protein synthesis, which is responsible for the impaired production IL-6 [Our results revealed a decreasing trend of plasma IL-6 in exposed workers compared to it in reference group. In addition, ion IL-6 . It is pion IL-6 . Lipids ion IL-6 , 35. AltFor subjects randomly selected from the populations, the rates of chronic hypertension and cardiovascular complications and pain were supposed to be similar in exposed and non-exposed groups. However, we found that the rates of chronic diseases and health complaints  in exposed workers were significantly higher that reference group. There may be an association between the health status and ELF-EMF-induced oxidative stress. Oxidative stress plays critical role in several chronic complications including hypertension, cardiovascular complications, dyslipidemia and depression –38. CommParticipants were recruited for the present study in Jilin First People's Hospital between September 2010 and August 2014. The Institutional Ethic Board of Jilin First People's Hospital has approved this study. Recruitment was advertised in a power plant in Jilin, China. In addition, we also invited the participants to advertise this project to their families and friends. Electrical line workers who are commonly exposed to 110–420 kV electricity lines were chosen as the experimental group. The main tasks of these electrical line workers are installing, repairing, and maintaining the high-voltage electricity lines. EFA-300 meter was used to measure the occupational EMF intensity with frequency ranging from 5 Hz to 32 kHz, and was placed under the high-voltage electricity lines. The electric range of the instrument is 0.1 V/m–316 kV/m, and the magnetic field range is 0.1 nT–32 mT, both of which have an accuracy of ± 3%. We found that the average intensity of EMF reached 1426 V/m for electric fields and 20 μT for magnetic fields. In order to ensure there was no significant exposure in the control group, we recruited families or friends of the workers in the power plant, and none of them was significantly exposed to high voltage electricity lines.All of the participants were confirmed to be healthy after physical examination, as well as blood and urine tests before enrollment. Doctors and trained nurses were sent to the power plant to collect blood and urine samples. Since the subjects in the reference group were not workers in the power plant, they went to the power plant on the day of sample collection. Informed consents were signed by all participants.2. Additionally, participants were excluded if they were smoker, alcoholic, or residentially exposed to high-voltage powerlines during their life time. All of these participants were Chinese, thus, the results of this study may only be applicable in Chinese population. None of the participants were exposed to hazardous chemicals and participants with previous electric shocks were excluded.The average time of occupational exposure to 110–420 kV was calculated according to the self-reported durations of daily occupational exposure. Enrolled participants were divided into two separate groups: 1) workers exposed to 110–420 kV for more than 20 years; 2) reference group without significant exposure. The characteristics of the two groups were recorded and compared. Inclusion and exclusion criteria of the current study were according to both scientific and ethical considerations, as illustrated in Figure For each group, the participants were randomized into two subgroups treated with either placebo or resveratrol. Resveratrol were supplied as dietary supplements to each participant (500 mg twice daily) for a period of 12 months. It was demonstrated that 28 days of resveratrol administration (2.5 or 5 g once daily) mg significantly decreased fasting and postprandial glucose and insulin in patients with type 2 diabetes . KennedyAt the end of study, 470 of them have completed the entire study protocol, whereas 610 were dropped out. After questionnaire, participants who had more than 20 hours self-reported physical exercise and comparative long computer and/or mobile phone usage time per week were excluded from participating in the following protocols in this study.Body height and weight of all participants were taken twice by trained staff of the hospital, who were blind to the group assignments. Body weight was measured with participants in light clothing and without shoes using a digital weighing scale at an accuracy of 0.1 kg. Body height was measured as a standing posture without shoes at an accuracy of 0.1 cm.An in-depth health history questionnaire, consisting of questions concerning information on demographics, hypertension, diabetes, alcohol intake and use of medication including vitamin supplementation, were issued to all enrolled participants. Participants who did not complete the questionnaire or were on regular vitamin supplementation were excluded from the study. According to previous studies, vitamins such as vitamin C and vitamin E and green tea may affect oxidative damage and total antioxidant capacity. However, because of the involvement of oxidative stress measurements in this study we excluded participants who have regular intakes of vitamin supplements and green tea to eliminate their influences.g. The supernatant was discarded, and the pellet was placed in a speed vacuum to vaporize the residual ethanol. All blood samples were collected under fasting conditions early in the morning at months 0 and 12 of resveratrol supplementation. Serum was obtained after centrifugation at 1,200 × g for 10 min at 4°C and stored at –80°C until further analysis. F2-isoprostanes were analyzed in the purified samples in triplicate via a competitive ELISA kit . The detection limit of this assay was 3 pg/ml. F2-isoprostane concentrations were normalized with creatinine concentration . Urinary 8-hydroxy-2-deoxy-guanosine (8-OHdG) was determined by the 8-OHdG EIA competitive assay Kit purchased from Cayman Chemical. The assay has a detection range from 10.3–3,000 pg/ml and a sensitivity of approximately 30 pg/ml. The level was normalized with creatinine . Serum melatonin level was measured by a commercial ELISA kit , which has a detection range 3.0–350 pg/ml, with intra- and inter-assay coefficients of variation (CV) 6.4% and 9.1%, respectively. Serum human heat shock protein (HSP70) was analyzed by HSP70 assay kit purchased from Bio Medical Assay  following manufacturer's manuals. The detection limits of this assay was < 0.05 ng/mL, and the intra- and inter assay CVs of HSP70 were 6.5% and 8.2% respectively. Nuclear factor kappa B (NF-κB) was determined by an ELISA kit  following manufacturer's manuals, and the intra- and inter-assay CVs were 5.7% and 8.2%, respectively. Serum high-sensitivity C-reactive protein (HRP) was assessed using an ELISA assay . The assay range was 46.9–3,000 pg/mL, and thentra- and inter-assay CVs were 5.1% and 4.7%, respectively. Serum IL-6 concentration was determined using an ELISA kit (R&D Systems), according to the manufacturer's instructions. The assay standard range was from 0.156 to 10 pg/ml, and the intra- and inter-assay CVs were 7.6% and 9.1%, respectively.Urine samples were collected from all participants at months 0 and 12 of resveratrol supplementation. For all participant, urine samples in 24 h were collected into plastic sample cups pre-filled with 3 g ascorbic acid, which were maintained at 4°C and were collected during the visit on the next day. We purified urine samples by mixing with 3× ethanol (in volume). All mixtures were cooled to 4°C, and then centrifuged for 20 min at 1500 × Ex vivo stimulated productions of IL-6, IL-8, IL-1β and TNF-α were measured as previous reported [g for 10 min. Supernatants were then frozen at −80°C until further cytokine measurements. Multiplex bead kits  were employed to test the stimulated levels of IL-1β, IL-6, IL-8 and TNF-α, with both inter- and intra-assay CVs less than 10%.reported  with citU test was employed for comparing abnormal distributed variables. Two or more ways ANOVA analysis were used to compare the differences in biomarker levels between exposed and reference groups. A student's paired t-test was used to compare the levels of each biomarker before and after resveratrol. SPSS/PC+™ software  was used for statistical analyses. Descriptive data is presented as mean ± standard deviation (SD). Differences were considered statistically significant at P < 0.05.All data were presented as mean ± standard deviation (SD). The Kolmogorov–Smirnov test or analysis of variance (ANOVA) was applied for continuous variables. The nonparametric Mann-Whitney In summary, the current study found that long-term occupational exposure to high-voltage electricity lines has an adverse effect on oxidative stress and immune response among workers. High oxidative stress and DNA damage risk have been observed in exposed workers compared to those in the reference group. Additionally, immune responses are comparably different in exposed workers from reference group. However, resveratrol significantly reversed the impacts of long-term exposure to ELF-EMF in workers. This study supported that occupational and long-term exposure to high-voltage electricity lines may play an adverse effect on human health, and resveratrol supplement could be effective as a protection strategy against ELF-EMFs. Our result only investigated prolonged and occupational exposure of ELF-EMF so that the results may not be applied for short term or other types of exposures to ELF-EMF.